Asian women, in general, and Vietnamese women, in particular, have been identified as ethnic groups that are not participating in breast cancer screening programs in the U.S. The reasons are complex and Vietnamese women may be especially vulnerable due to cultural variances in beliefs, health practices, language barriers, lack of access to care due to socio-economic factors, as well as the long term effects of the migration that occurred at the close of the Vietnam war.
A focus group was conducted to provide insight into the beliefs and attitudes that guide Vietnamese women’s health care seeking behavior. Five group members were recruited through collaboration with the Community House Calls Program at Harborview Medical Center. The women’s ages ranged from 63 to 93, their length of stay in the U.S. ranged from 8 years to 16 years. Since none of the group members spoke English, a Vietnamese woman who works with the Community House Calls Program acted as interpreter during the focus group session.
Asian women living in the United States have significantly lower breast cancer incidence and mortality rates than Caucasian women (Miller, et al., 2008). Breast cancer incidence among Vietnamese women is 53 per 100,000 women, compared to 145 per 100,000 for Caucasian women (Miller, et al., 2008). The incidence rate for U.S. Caucasian women in 1980 was two and a half to four times that of women living in China, Japan, or the Philippines (Ziegler, et al., 1993). While the risk among Asians living in the U.S. is relatively low compared to Caucasian women, there is increasing concern that breast cancer risk rises after migration to the U.S. For Asian-American women born in the U.S., the risk approaches that of Caucasian women (Ziegler, et. al., 1993). Although breast cancer incidence among Vietnamese women is comparatively low, their risk for late stage disease is high due to inadequate screening, conflict among patient and provider, poor access to care, and economic limitations.
A study by Ziegler, et. al. (1993) determined that Asian-American women born in the West had a breast cancer risk 60% higher than Asian-Americans born in the East. The study also noted that Asian-American women with three or four grandparents born in the West had a risk 50% higher than those with all grandparents born in the East. Also, immigrants who lived in the West for ten years or longer had a risk 80% higher than more recent immigrants. Although studies are lacking as to why the risk increases with longer stays in the U.S., there is strong speculation that this is mainly due to acculturation to diet, environment, and cultural barriers (Ziegler, et. al.,1993).
On the basis of international comparisons and migration studies, it is postulated that breast cancer exposure among Asian women in the U.S. is related to lifestyle, environment, and the use of endogenous hormones. These factors may be the cause of the discrepancy in breast cancer incidence rates. The statistical discrepancy between Asian and Caucasian women may serve to minimize the perception of breast cancer as a health threat for Asian women in the U.S., and it is possible that a false sense of security exists among this population. Even more disconcerting is the possibility that American health care providers, who are responsible for the education and referral of these women for breast cancer screening, may play a role in perpetuating the illusion that screening and prevention efforts do not need to be as directed toward Asian women as they are toward the Caucasian population.
Demographic Overview of the Vietnamese Population
The Vietnamese population has been the fastest growing Asian-American ethnic group in the United States. In 1980 there were approximately 261,000 Vietnamese living in this country and by 1990 it had increased to 615,000 (Pham and McPhee, 1992). In comparison, in Washington state, there was a 90% increase in the Vietnamese population between 1980 and 1990. The 1990 census reports that there are 11,030 people in King County who describe themselves as Vietnamese, making this the fourth largest Asian population in Seattle.
Clinicians should be aware that while the misperception of Asians as a “model minority” who are all well educated and prosperous persists, recent studies report that 14% of Asian-Americans live in poverty in this country. Also, it is important to note that many Asian immigrants are refugees who have fled war and political oppression. According to Barker (1992), all physicians in major U.S. cities can expect to provide care to patients who have been tortured or treated under very cruel circumstances. These patients are from not only Vietnam, but also Cambodia, the Middle East, Ethiopia, and Eastern Europe. Health prevention practices may not be a priority for these women who are faced with more daunting matters.
Cultural Knowledge and Traditional Treatment
In Vietnam, a wide variety of religions such as the Taoist-Confucianist-Mahayana Buddhist outlook, Catholicism, Protestantism, and Cao Daism (a mixture of Buddhism, Taoism, Confusionism, Catholicism, and Indian mysticism) all co-exist along with other popular beliefs and practices (Schreiver, 1990). Vietnamese religions are pervasive and have many affiliations, but share a common cosmology: Chinese philosophy influences the believer’s every daily act, including their health care practices (Schreiver, 1990). Concepts center around universal order and harmony guiding individual destiny. Illness is viewed as a disruption in order and harmony. It may be perceived as a natural occurrence due to improperly stored food, to be treated by an array of folk medicines, or it may be seen to be the result of supernatural causes (Schreiver, 1990). In traditional Chinese medicine, an imbalance of Yin and Yang can cause illness, as can the Hot and Cold phenomenon, which is common to many cultures. Traditional healers are viewed as having extraordinary powers and should be able to identify the patient’s problems on first sight, or after taking the pulse. The need for a lengthy history, physical examination, blood drawing, or requiring a patient to undress may be viewed as incompetence (Schreiver, 1990). Believers see surgery of any kind as a disruption in harmony and it thus should only be done as a last resort. Hospitalization often signifies death (Schreiver, 1990).
Translation and Language Equivalents
Although the Vietnamese have two words for breast cancer, “ung thu nhu hoa” or “ung thu vu,” most of the women in the focus group stated that they had never heard of breast cancer until they came to the U.S. One woman stated that cancer is scary and that in Vietnam many women die from breast cancer. Another respondent stated that most Vietnamese women do not pay attention to their breasts; when they do find out that there is a problem, it is too late.
Clinical Features of Screening and Treatment
Breast Cancer Screening Practices Among Vietnamese Women in King County According to the Ethnicity and Health Survey conducted by the Seattle-King County Public Health Department from 1995-1996, screening rates for both clinical breast exam and mammogram were considerably lower among Vietnamese women than the rates for all of King County. In the Reproductive Health Survey among Indo-Chinese immigrants conducted in Seattle from 1994-1995, Vietnamese women were the most likely to have never heard of a mammogram. Regarding breast self examination, one-third said they did not know how to conduct the exam, while 30% admitted they never thought to do it. Twenty-nine percent felt it was not necessary to do the exam. The conclusion was that most women did not perform breast exams due to lack of knowledge and motivation.
A study examining the cultural reasons for under use of medical services by Southeast Asian refugees found that this group values stoicism and views suffering and illness as a part of life and thus may not seek medical care until the later stages of disease (Uba, 1992). Pham and McPhee (1992) examined knowledge, attitudes, and practices regarding breast and cervical cancer screening among Vietnamese women through surveys of 400 women in San Francisco. They concluded that more than half of the respondents believe that there is nothing one can do to prevent cancer. This view correlates with the cultural belief that illnesses are pre-destined (Uba,1992). One-third of respondents did not know that a breast lump could be a sign of breast cancer and over one-half did not know that family history was a risk factor for breast cancer. Sixty-four percent had not heard of a mammogram. Even when financial barriers were removed, Asian-American screening rates were still lower than those of Caucasian women (Tu, et al., 1999).
Pham and colleagues found that significant barriers to breast cancer screening were: a lack of physician recommendation, the patient’s own lack of knowledge, embarrassment, cost, and language difficulty. A study of health care access and preventive care among Vietnamese immigrants discovered that traditional beliefs and practices are not as significant barriers to health care access as lack of health insurance and lack of a regular health care provider (Jenkins 1996). Married women have greater access to health care as pregnancy and childbirth provide points of entry into the health care system. Those with a household income below the poverty level are provided access through public assistance programs. This leaves many without access to preventive health care screening programs (Jenkins, et. al.,1996).
Insights From the Focus Group
When the focus group members were asked where and when they went for health care, three of the women said they saw Vietnamese physicians, and two said they went to “American” doctors. All the women had similar responses regarding when they sought health care: only when they were sick. One woman said that she has never gone to the doctor specifically for breast cancer screening or a general check up. She went on to say, “there is nothing wrong with my breasts, why should I have to go to the doctor? I only have a problem with my eyes.” Another woman stated that Vietnamese women would do self breast exams if they knew how and why it is done, and another respondent stated that more women would do it if they knew about breast cancer. Several women stated that they liked having pictures which demonstrated how to do self breast exams. Only two of the women in the group (the two youngest) had ever had a mammogram. The oldest woman stated that she had never had a mammogram and said she would not know where to go since “nobody told me.”
Recommendations for providers
Many factors can affect compliance with screening and treatment. The points that I found to be most important for health care providers to be aware of are as follows:
- There is a lack of screening among Vietnamese women due to differences between the Western model of health care delivery and traditional beliefs. Without symptoms, why go to the doctor?
- Vietnamese women lack awareness of breast cancer screening and mammography.
- Since Vietnamese women are often unaware of breast cancer screening practices, clinicians should be sure to recommend screening when appropriate.
- Elderly and rural Vietnamese women may distrust Western medicine. Such patients often appear polite and compliant and will not question authority. They often do not comply with screening recommendations due to misunderstanding.
- When faced with possible symptoms, these women may first seek assistance with non-Western healers such as shaman, who share their cultural and world views.
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